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Alte Version 39

changes.mady.by.user Tharsika Keßler

Gespeichert am

verglichen mit

Neue Version Aktuell

changes.mady.by.user Joana Griesler

Gespeichert am

Schlüssel

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...

  • PatientIn, Stempelinformationen des Arztes/der Klinik/der mitbetreuenden Hebamme, Stempelinformationen des LaborsztesLaborarztes/der Laborärztin und des Laboratoriums, Eintragende Person und Eintragende Einrichtung → Einrichtung → Anpassung an die Kardinalitäten dr der KBV-Basis-Profile in der Version 1.1.3
  • Geburtsdatum der Patientin → die zweite Bedingung ist nun "Nicht erlaubt"
  • Bei mehreren Elementen → statt "required" nun "optional"
  • Immunität anzunehmen → statt "conditional" nun "required"
  • I. Ultraschallscreening → nun 0..2 

...

  • Beim I. und III. Ultraschallscreening
  • Beim Katalog A


1.2 Codierung


Aktualisierung

...

der Codes an aktuelles SNOMED CT® Release

Im Zuge des International Release 2021-07-31 wurden die Codes und Bezeichnungen (fully specified names) der Konzepte vollständig überarbeitet. Anpassung aller Codes und Bezeichnungen im Code-System.


Element im InformationsmodelVersion 1.0.0Version 1.1.0
Plazentalokalisation/-struktur normal169954003 Placenta normal O/E (finding)289279004 Placenta healthy (finding)
Erythrozyten im Blut, Anzahl pro Volumen363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=703062004,370132008=30766002,704318007=118550005Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Population of all erythrocytes in portion of fluid (body structure) , Scale type (attribute) = Quantitative (qualifier value) , Property type (attribute) = Number concentration (property) (qualifier value)363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=703062004,370132008=30766002,370130000=118550005Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Population of all erythrocytes in portion of fluid (body structure) , Scale type (attribute) = Quantitative (qualifier value) , Property (attribute) = Number concentration (property) (qualifier value)
Chlamydia trachomatis DNA aus einer Urinprobe mittels Nukleinsäure-amplifizierendem Test (NAT), Nachweis363787002:246093002=121181000,370134009=123029007,704327008=122575003,246501002=702675006,370132008=117363000,704318007=705057003,704319004=78014005Observable entity (observable entity) : Component (attribute) =  Deoxyribonucleic acid of Chlamydia trachomatis (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Urine specimen (specimen) , Technique (attribute) = Probe with target amplification technique (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Property type (attribute) = Presence (property) (qualifier value) , Inheres in (attribute) =  Urine (substance)363787002:246093002=121181000,370134009=123029007,704327008=122575003,246501002=702675006,370132008=117363000,370130000=705057003,704319004=78014005Observable entity (observable entity) : Component (attribute) =  Deoxyribonucleic acid of Chlamydia trachomatis (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Urine specimen (specimen) , Technique (attribute) = Probe with target amplification technique (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Property (attribute) = Presence (property) (qualifier value) , Inheres in (attribute) =  Urine (substance)
Hämoglobin im Blut, Mol pro Volumen363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=38082009,704318007=118556004,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Property type (attribute) = Substance concentration (property) (qualifier value) , Scale type (attribute) = Quantitative (qualifier value)363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=38082009,370130000=118556004,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Property (attribute) = Substance concentration (property) (qualifier value) , Scale type (attribute) = Quantitative (qualifier value)
Hämoglobin im Blut, Masse pro Volumen363787002:704319004=87612001,704318007=118539007,704327008=119297000,370134009=123029007,246093002=38082009,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Property type (attribute) = Mass concentration (property) (qualifier value) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Scale type (attribute) = Quantitative (qualifier value)363787002:704319004=87612001,370130000=118539007,704327008=119297000,370134009=123029007,246093002=38082009,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Property (attribute) = Mass concentration (property) (qualifier value) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Scale type (attribute) = Quantitative (qualifier value)
HBs-Antigen im Serum, Nachweis363787002:370134009=123029007,370132008=117363000,704319004=50863008,246093002=22290004,704318007=705057003,704327008=119364003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Component (attribute) = Antigen of Hepatitis B virus surface protein (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:370134009=123029007,370132008=117363000,704319004=50863008,246093002=22290004,370130000=705057003,704327008=119364003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Component (attribute) = Antigen of Hepatitis B virus surface protein (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Titer363787002:246093002=120737006,704318007=118590008,370134009=123029007,370132008=30766002,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Property type (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370130000=118590008,370134009=123029007,370132008=30766002,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Property (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Konzentration IE pro Volumen363787002:246093002=120737006,370134009=123029007,370132008=30766002,704318007=118569000,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Property type (attribute) = Arbitrary concentration (property) (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370134009=123029007,370132008=30766002,370130000=118569000,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Property (attribute) = Arbitrary concentration (property) (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Nachweis363787002:246093002=120737006,370134009=123029007,370132008=117363000,704319004=50863008,704318007=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370134009=123029007,370132008=117363000,704319004=50863008,370130000=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
Blutgruppen Antikörper-Suchtest im Serum/Plasma, Titer363787002:704318007=118590008,370134009=123029007,704327008=122592007,370132008=30766002,246093002=19830006,704319004=50863008Observable entity (observable entity) : Property type (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Scale type (attribute) = Quantitative (qualifier value) , Component (attribute) = Blood group antibody (substance) , Inheres in (attribute) = Blood group antibody (substance)363787002:370130000=118590008,370134009=123029007,704327008=122592007,370132008=30766002,246093002=19830006,704319004=50863008Observable entity (observable entity) : Property (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Scale type (attribute) = Quantitative (qualifier value) , Component (attribute) = Blood group antibody (substance) , Inheres in (attribute) = Blood group antibody (substance)
Blutgruppen Antikörper-Suchtest im Serum/Plasma, Nachweis363787002:370134009=123029007,704327008=122592007,246093002=19830006,370132008=117363000,704319004=50863008,704318007=705057003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Component (attribute) = Blood group antibody (substance) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property type (attribute) = Presence (property) (qualifier value)363787002:370134009=123029007,704327008=122592007,246093002=19830006,370132008=117363000,704319004=50863008,370130000=705057003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Component (attribute) = Blood group antibody (substance) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property (attribute) = Presence (property) (qualifier value)
AB0-System363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=106202009Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in ABO blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,118598001=410656007,246093002=106202009Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in ABO blood group system (substance)
Rhesus-System363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,118598001=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)

Rhesus-System

363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,370130000=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)

Laboruntersuchung (LSR)

363787002:246093002=120723002,370134009=123029007,370132008=117363000,704319004=50863008,704318007=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Treponema pallidum antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120723002,370134009=123029007,370132008=117363000,704319004=50863008,370130000=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Treponema pallidum antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
pH-Wert (Nabelarterie)363787002:370134009=123029007,704319004=12499000,246093002=89177007,704318007=702700007,370132008=30766002,704327008=703430008Observable entity (observable entity):Time aspect (attribute)=Single point in time (qualifier value),Inheres in (attribute)=Cord blood (substance),Component (attribute)=Proton (substance),Property type (attribute)=Logarithmic substance concentration (property) (qualifier value),Scale type (attribute)=Quantitative (qualifier value),Direct site (attribute)=Arterial cord blood specimen (specimen)363787002:370134009=123029007,704319004=12499000,246093002=89177007,370130000=702700007,370132008=30766002,704327008=703430008Observable entity (observable entity):Time aspect (attribute)=Single point in time (qualifier value),Inheres in (attribute)=Cord blood (substance),Component (attribute)=Proton (substance),Property (attribute)=Logarithmic substance concentration (property) (qualifier value),Scale type (attribute)=Quantitative (qualifier value),Direct site (attribute)=Arterial cord blood specimen (specimen)

Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)

365638007Finding of Rh blood group (finding)365638007 + 160499008Finding of Rh blood group (finding) + Child of (finding)

Vaginale Untersuchung

275963006On examination - vaginal examination (finding)113023007Examination of vagina (procedure)
vag. Operation

129125009:{363589002=236974004,408730004=398166005}

Procedure with explicit context (situation):{Associated procedure (attribute)=Instrumental delivery (procedure),Procedure context (attribute)=Performed (qualifier value)}236974004Instrumental delivery (procedure)
Sektio

200144004

Deliveries by cesarean (finding)

11466000Cesarean section (procedure)
Spontangeburt

169961004

Normal birth (finding)

177184002Normal delivery procedure (procedure)

Kind verlegt am 243796009:{363589002=37729005,408732007=67822003}

Situation with explicit context (situation) : { Associated procedure (attribute) = Patient transfer, in-hospital (procedure) , Subject relationship context (attribute) = Child (person) }


107724000Patient transfer (procedure)

Herzaktion



277766008

Awareness of heart beat (finding)249045009Fetal heart sounds present (finding)
0h (Bombay)115733006Blood group O>h< Bombay Indian variant (finding)115731008Blood group O>h< Bombay (finding)
U3 durchgeführt713020001Child into care medical examination done (situation)444084004Child examination with explicit context (situation)
Stationäre Behandlung während der Schwangerschaft5491000179105Medical record summary (record artifact)422735006Summary clinical document (record artifact)
Thorax - Auffällige Herz/Thorax-Relation (Blickdiagnose)441920005Radiographic shadow of heart abnormal (finding)249042007:47429007=65476007Fetal heart finding (finding) : Associated with (attribute) = Abnormal size (finding)

Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)

365638007+160499008Finding of Rh blood group (finding) + Child of (finding)365638007+118188004Finding of Rh blood group (finding) + Finding of neonate (finding)

Angaben zum Kind

118188004Finding of neonate (finding)

133906008 : 363702006 = 118188004

Postpartum care (regime/therapy) : Has focus (attribute) : = Finding of neonate (finding) 

AU (Abdomen/Thorax-Umfang)396552003:704321009=268445003Abdominal circumference (observable entity) : Characterizes (attribute) = Ultrasound scan - obstetric (procedure)1156896009Thoracoabdominal circumference of fetus (observable entity)
FOD (Fronto-okzipitaler Durchmesser)304602002:704327008=3332001

Antenatal ultrasound finding (observable entity) : Direct site (attribute) = Occipitofrontal diameter of head (body structure)

1156893001Occipitofrontal diameter of fetal head (observable entity)
FS (Fruchtsackdurchmesser)248326004:704325000=70847004Body measure (observable entity) : Relative to (attribute) = Structure of amnion (body structure)1156895008Diameter of amniotic sac (observable entity)
Embryo darstellbar404684003:{418775008=446522006,363698007=609524001,363713009=52101004}Clinical finding (finding):{Finding method (attribute)=Ultrasonography in first trimester (procedure)|,Finding site (attribute)=Entire embryo proper (body structure),Has interpretation (attribute)=Present (qualifier value)}1157306001Embryo present in utero (finding)
Gynäkologischer Befund normal404684003:{363714003=83607001,363713009=17621005}Clinical finding (finding):{Interprets (attribute)=Gynecologic examination (procedure),Has interpretation (attribute)=Normal (qualifier value)}1157297002Gynecologic examination normal (finding)
Diagnosetest auffällig nein

166926006

Glucose tolerance test normal (finding)

1156100006Pregnancy with normal glucose tolerance test (finding)
Beratung über ausreichende Jodzufuhr während der Stillzeit erfolgt409066002:363702006=438901000124107Education, guidance and counseling (procedure) : Has focus (attribute) = Iodine supplement therapy (regime/therapy)1157300007Education about iodine supplement therapy (procedure)
Krebsfrüherkennungsuntersuchung409066002:363702006=15886004Education, guidance and counseling (procedure): Has focus (attribute) = Screening for cancer (procedure)1156103008Education about screening for malignant neoplasm (procedure)
Schwangerschaftswoche+Tage57036006Fetal gestational age (observable entity)1156738004Fetal gestational age in weeks and days (observable entity)
Schwangerschaftswoche+Tage (korrigiert)57036006:246501002=278395004Fetal gestational age (observable entity):Technique (attribute)= Imaging technique (qualifier value)1157308000Corrected fetal gestational age in weeks and days (observable entity)
Rumpf - Darstellbarkeit des Magens im linken Oberbauch302292003:363714003=(364146002:704327008=86367003)Finding of trunk structure (finding) : Interprets (attribute) = ( Stomach observable (observable entity) : Direct site (attribute) = Structure of left upper quadrant of abdomen (body structure) )1157188005Stomach present in left upper quadrant of abdomen (finding)
Kopf Darstellbarkeit des Kleinhirns406122000+106112009+106111002:{363698007=113305005}

Head finding (finding) + Fetal finding (finding) + Clinical sign related to pregnancy (finding) : { Finding site (attribute) = Cerebellar structure (body structure) }

1157174006Cerebellum present (finding)
(21) Komplikationen bei vorausgegangenen Entbindungen417662000:{408731000=410513005,408729009=410515003,246090004=199745000,408732007=410604004}History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value), Finding context (attribute) = Known present (qualifier value),Associated finding (attribute) = Complication occurring during labor and delivery (disorder), Subject relationship context (attribute) = Subject of record (person)}1156096005History of complication occurring during labor and delivery (situation)
(22) Komplikationen post partum417662000:{408731000=410513005,408729009=410515003,246090004=80113008,408732007=410604004}History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value), Finding context (attribute) = Known present (qualifier value), Associated finding (attribute) = Complication of the puerperium (disorder), Subject relationship context (attribute) = Subject of record (person)}1156097001History of complication of puerperium (situation)
(8) Rhesus-Inkompatibilität (bei vorangegangenen Schwangerschaften)312850006:246090004=44795003History of disorder (situation):Associated finding (attribute)=Rhesus isoimmunization affecting pregnancy (disorder)1156098006History of Rhesus isoimmunization affecting pregnancy (situation)
Rumpf - Darstellbarkeit der Harnblase

441687008:{363713009=17621005,363714003=169251004}

Imaging of genitourinary system abnormal (finding):{Has interpretation (attribute)=Normal (qualifier value),Interprets (attribute)=Ultrasound scan of bladder (procedure)}

1157173000Bladder present (finding)
Perzentil363787002:370130000=118583003Observable entity (observable entity) : Property (attribute) = Percentile (property) (qualifier value)1157309008Percentile of fetal growth (observable entity)
(24) Zustand nach anderen Uterusoperationen416940007:363589002=79876008Past history of procedure (situation): Associated procedure (attribute) = Operation on uterus (procedure)1156095009History of operation on uterus (situation)
Schwangerschaft festgestellt am/in der74036000:370130000=410672004Pregnancy detection examination (procedure) : Property (attribute) = Date property (qualifier value)|1156894007Date of pregnancy detection (observable entity)
Thorax - Darstellbarkeit des Vier-Kammer-Blicks

169221005:363698007=43487005

Ultrasound obstetric scan normal (finding):Finding site (attribute)=All chambers of the heart (body structure)1157164008All chambers of heart present (finding)
Zum HIV-Antikörpertest409066002:363702006=165813002

Education, guidance and counseling (procedure): Has focus (attribute) = Human immunodeficiency virus antibody test (procedure)

1156102003Education about screening for human immunodeficiency virus (procedure)
Kontrollbedürftig129125009:408730004=410525008Procedure with explicit context (situation) : Procedure context (attribute) = Needed (qualifier value)

1157303009

Requires follow-up (finding)
Thorax - Persistierende Arrythmie im Untersuchungszeitraum

249042007:246090004=(698247007:371881003=243788004)

Fetal heart finding (finding) : Associated finding (attribute) = Cardiac arrhythmia (disorder) : During (attribute) = Child examination (procedure) )289444003:371881003=243788004Irregular fetal heart rhythm (finding) : During (attribute) = Child examination (procedure)

...

Aufnahme der Codes für folgende Elemente

  • Pertussis-Impfung
CodeBezeichnung im Code-SystemCode-System
132751000119107Diphtheria, tetanus and acellular pertussis vaccination given (situation)SNOMED Clinical Terms
  • Bestimmung des fetalen
    • Rhesus
  • RhD-Status
CodeBezeichnung im Code-SystemCode-System
365638007+106112009Finding of Rh blood group (finding) + Fetal finding (finding)

SNOMED Clinical Terms

  • Angaben zur Mutter
CodeBezeichnung im Code-SystemCode-System
133906008Postpartum care (regime/therapy)SNOMED Clinical Terms

Aufnahme des LOINC® Codes als Mapping zu dem dazugehörigen gemappten SNOMED CT® Codes

  • Körpergewicht 
CodeBezeichnung im Code-SystemCode-System
29463-7Body weightLOINC®


Anpassung des Codes beim Element 'Wochenbett'

...

  • Aufteilung von KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth in KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth_Child und KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth_Mother
  • Aufteilung von KBV_PR_MIO_MR_Observation_Examination in KBV_PR_MIO_MR_Observation_Examination und KBV_PR_MIO_MR_Observation_Examination_Masked
  • Ergänzung der ConceptMap an KBV_PR_MIO_MR_ClinicalImpression_Pregnancy_Examination_Discharge_Summary.finding
  • KBV_PR_MIO_MR_Observation_Para.value[x] und KBV_PR_MIO_MR_Observation_Gravida.value[x] → valueInteger statt valueQuantity
  • Ergänzung von MustSupports in KBV_PR_MIO_MR_DiagnosticReport_Ultrasound_II und KBV_PR_MIO_MR_DiagnosticReport_Ultrasound_III
  • KBV_PR_MIO_MR_Observation_Previous_Pregnancy: Constraint zur Begrenzung der Länge des Date auf 4 Stellen
  • KBV_PR_MIO_MR_Procedure_Counselling → Ergänzung des fixed Value des Status
  • KBV_PR_MIO_MR_Observation_Baseline_Weight_Mother → Ergänzung des fixed Value des Codes und Löschung des ValueSets
  • KBV_PR_MIO_MR_Patient_Child, KBV_PR_MIO_MR_Practitioner und KBV_PR_MIO_MR_Composition → Ergänzung der Profil-Definition
  • KBV_PR_MIO_MR_Patient_Child: Als Identifier wird für das Kind nicht mehr die Nummer-Extension am Identifier verwendet, sondern die pid, die in Form einer UUID vorliegen muss
  • KBV_PR_MIO_MR_Observation_Weight_Child → Ergänzung der Version in meta.profile
  • Anpassung der Referenzen in Sections der Composition → viele Observations sind nicht mehr direkt in der Composition sondern über die dort referenzierten DiagnosticReports und ClinicalImpressions referenziert 
  • KBV_PR_MIO_MR_Observation_Cardiotocography.code.coding.display.extension → Anpassung des fixedValue 
  • Da sich KBV_PR_MIO_MR_ClinicalImpression_Birth_Examination_Child_Information auf das geborene Kind bezieht, referenziert es jetzt nicht mehr die Mutter sondern das Kind als subject.

...

Ergänzung von Leerzeichen beim Hinweistext



2. Änderungen im Vergleich zur Version 1.1.0 Kommentierung

2.1 Informationsmodell

Inhaltliche Anpassungen:

  • Ergänzung folgenden Elements: "Entbindungstermin (ggf. nach Verlauf korrigiert)“ im Format TT/MM/JJJJ
  • Anpassung des Datentyps bei pH im Abschnitt Geburt auf 2 Nachkommastellen
  • Anpassung der Bezeichnung ValueSet Geburtsmodus auf "vaginal operativ"
  • Hämoglobin wird nur noch in g/dL dargestellt in Anlehnung an die Angaben aus den Mu-RL

Redaktionelle Anpassungen:

  • Ergänzung des Beschreibungstextes für die Erläuterung der Schwangerschaftswoche+Tage wie folgt: "Eine Schwangere, die beispielsweise 40+3 (=40 Wochen und 3 Tage) schwanger ist, befindet sich demnach in der 41. SSW."
  • Anpassung der Rationale (überall): Link verweist auf die Seite mit der jeweils gültigen Anlage 3 zu den Mu-RL
  • Schreibweise beim Element fetaler Rhesus-Status angepasst auf fetaler RHD-Status (kursiv und großgeschrieben) → dies entspricht laut G-BA Beschluss vom 19.08.2021 der korrekten Nomenklatur

Aufnahme von Operationalisierungshinweisen:

  • Übergreifender Operationalisierungshinweis zum Umgang mit verschiedenen MIO-Versionen
  • Hinweis beim Rhesus-Status der Mutter


2.2 Codierung

Anpassung folgender Codes:

Element im InformationsmodelVersion 1.1.0 KommentierungVersion 1.1.0 Benehmensherstellung
Diagnosetest386053000:{363702006=271062006,363702006=442260000,363702006=49167009} Evaluation procedure (procedure) : {Has focus (attribute) = Fasting blood glucose measurement (procedure), Has focus (attribute) = Measurement of glucose 1 hour after glucose challenge for glucose tolerance test (procedure), Has focus (attribute) = Measurement of glucose 2 hours after glucose challenge for glucose tolerance test (procedure)}699731004  |Glucose tolerance test, antenatal (procedure)|

Bestimmung des fetalen RHD-Status

365638007 + 106112009  |Finding of Rh blood group (finding)| + |Fetal finding (finding)|365645007 + 106112009|Finding of Rh genotype (finding)| + |Fetal finding (finding)|

Ultraschall - Plazentalokalisation/-struktur normal

Der alte Code 169954003 |Placenta normal O/E (finding)| ist bei SNOMED inaktiv daher wird der Code postcodiert.

289279004 |Placenta healthy (finding)|169952004  : 260245000  = 17621005 |Placental finding (finding)| : |Finding value (qualifier value)| =  |Normal (qualifier value)|
Auffällige Herz-Thorax-Relation (Blickdiagnose)249042007:47429007=65476007Fetal heart finding (finding) : Associated with (attribute) = Abnormal size (finding)370380004  : { 363713009  = 394845008  } { 363714003 = ( 282290005: 704327008  = 80891009+ 51185008  } { 370130000 = 118593005  }|Ultrasound scan finding (finding)| : { |Has interpretation (attribute)| = |Potentially abnormal (qualifier value)| } { |Interprets (attribute)| = ( |Imaging interpretation (observable entity)| : |Direct site (attribute)| = |Heart structure (body structure)| + |Thoracic structure (body structure)| ) } { |Property (attribute)| = |Relative ratio (property) (qualifier value)| }
Vaginale Untersuchung113023007 |Examination of vagina (procedure)|113023007 + 51597003 |Examination of vagina (procedure)| + |Manual palpation of vagina (procedure)|
Berechneter Entbindungstermin

161714006


Estimated date of delivery (observable entity)|


289206005


 |Estimated date of delivery from last period (observable entity)|

Berechneter Entbindungstermin11778-8 Delivery date Estimated11779-6 Delivery date Estimated from last menstrual period
Blutgruppen-System-RH_MP

165747007 |RhD positive (finding)|

|RhD positive (finding)|365645007 + 165747007 |Finding of Rh genotype (finding)| + |RhD positive (finding)|
Blutgruppen-System-RH_MP165746003 |RhD negative (finding)|365645007  + 165746003|Finding of Rh genotype (finding)| +  |RhD negative (finding)|


Aufnahme folgender Codes:

Entbindungstermin (ggf. nach Verlauf korrigiert):

  • 738070007 |Estimated date of delivery from antenatal ultrasound scan (observable entity)|
  • 90368-2 Deliery date Estimated from physical exam


Aktualisierung der LOINC® auf die Version 2.71 



2.3 Technische Spezifikation


Anpassung spezifischer Codes

  • Entsprechend den in Abschnitt 2.2 erwähnten Aktualisierungen

Anpassung folgender Profile

  • Gravida und Para → Änderung von valueInteger auf valueQuantity



3. Änderungen im Vergleich zur Version 1.1.0 Benehmensherstellung

3.1 Codierung

  • Anpassung der Codes bei den Terminologie Assoziationen zu folgenden Elementen: